Nebraska Department of Transportation Nebraska Route Survey Form Note: Form must be typed, complete.	Application(s) No.:

Carrier’s Name:
Address: City: State: Zip:
Phone No.: Email Address:
Load Description:
Width: Height: Length of truck and trailer including any overhang:
Does trailer have rear-steerable axles? Yes No

Route Survey Completed By:

Company Name:
Address: City: State: Zip:
Phone No.: Email Address:
Survey Driver’s Name:

Route Description:

Starting Point in NE:
Route:
Ending Point in NE:

I certify that on	I physically completed the above route survey with a height pole set
(MM/DD/YY)
at	feet	inches. No obstructions were encountered at or below the height of this load or
that would cause property damage or block oncoming traffic for a load of this height (unless noted below).

Height Exceptions: (Use additional typed sheet(s), if necessary.)

I certify that on	I physically completed the above route survey and encountered no
(MM/DD/YY)
problems making turns due to the length of the truck and trailer combined that would cause property damage
or block oncoming traffic for a load of this length (unless noted below).

NDOT Form 85, July 2021	Page 1 of 2

Length Exceptions: (Use additional typed sheet(s), if necessary.)

I certify that on	I physically completed the above route survey and encountered no
(MM/DD/YY)
problems due to the width of this load that would cause property damage or block oncoming traffic for a load
of this width (unless noted below).

Width Exceptions: (Use additional typed sheet(s), if necessary.)

Survey Driver’s Signature: Print Name:

Typed or electronic signatures will not be accepted.

Following section must be completed by applicant/carrier for loads 16 feet or higher.

Are any utility lines affected by this move?	Yes – Complete Certification below and sign route survey

No – Sign route survey form

Certification

Applicant/Carrier certifies and affirms under oath the following:

As of	I have contacted the electrical utilities affected by this move and made
(MM/DD/YY)
arrangements with said utilities for the safe movement of this load under any lines owned by said utilities.

Consult www.nrea.org for a list and map of electrical utilities.

Applicant/Carrier Signature: Print Name:
Phone No.: Title:

Email Survey to NDOT Permit Office at ndot.ntpsweb@nebraska.gov

Fax: (402) 479-3918

Survey is valid for 30 days from date of completion.

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